What are the symptoms?

Depending on the cause, low back pain can cause a range of symptoms. The pain may be dull or sharp. It may be in one small area or over a broad area. You may have muscle spasms.

Low back pain can also cause leg symptoms, such as pain, numbness, or tingling, often extending below the knee.

A rare but serious problem called cauda equina syndrome can occur if the nerves at the end of the spinal cord are squeezed. Seek emergency treatment if you have weakness or numbness in both legs or you lose bladder or bowel control.

Most low back pain is short-term (acute) and will go away in a few weeks. It is more likely to become long-lasting (chronic) if you are depressed or under stress.

How is low back pain diagnosed?

Your doctor will ask questions about your past health, symptoms, and activities. He or she will also do a physical examination. Your answers and the examination can help rule out a serious cause for the pain. In most cases, doctors are able to recommend treatment after the first examination.

But if you have a back pain problem that has lasted longer than 6 weeks, or if your doctor thinks you may have more than muscle pain, it might be time for one of these tests.

How is it treated?

Most low back pain will improve with basic first aid, which includes continuing to do light activity such as walking, and taking over-the-counter pain medicine as needed.

Walking is the simplest and maybe the best exercise for the lower back. It gets your blood moving and helps your muscles stay strong.

Your doctor or physiotherapist can recommend more specific exercises to help your back muscles get stronger. These may include a series of simple exercises called core stabilization. Strengthening the muscles in your trunk can improve your posture, keep your body in better balance, and lower your chance of injury.

If your symptoms are severe or you still have symptoms after 2 weeks of self-care, see your doctor. You may need stronger pain medicines, or you might benefit from manual therapy.

Each of the various treatments for back pain work for some people but not for others. You may need to try different things to see which work best for you, such as:

Spinal manipulation.

Massage.

Acupuncture.

Having ongoing (chronic) back pain can make you depressed. In turn, depression can have an effect on your level of pain and whether your back gets better. People with depression and chronic pain often benefit from both antidepressant medicines and counselling. Counselling can help you learn stress management and pain control skills.

How can you prevent low back pain from returning?

After you've had low back pain, you're likely to have it again. But there are some things you can do to help prevent it. And they can help you get better faster if you do have low back pain again.

To help keep your back healthy and avoid further pain:

Practice good posture when you sit, stand, and walk. "Good posture" generally means your ears, shoulders, and hips are in a straight line.

Get regular, low-impact exercise. Walk, swim, or ride a stationary bike. Stretch before you exercise.

Spinal tumours, which are growths on the bones and ligaments of the spine, on the spinal cord, or on nerve roots.

Symptoms

Symptoms of low back pain depend on the cause.

Back sprain or strain

Symptoms typically include:

Muscle spasms, cramping, and stiffness.

Pain in the back and sometimes in the buttock. It may come on quickly or gradually. It most often occurs in episodes. Certain movements make it worse, and doing light activities such as walking makes it feel better. The worst pain usually lasts 48 to 72 hours and may be followed by days or weeks of less severe pain.

Nerve-root pressure

Symptoms typically include:

Leg pain. If pain extends below the knee, it is more likely to be due to pressure on a nerve than to a muscle problem. Most commonly, it's a pain that starts in the buttock and travels down the back of the leg as far as the ankle or foot. This pain pattern is known as sciatica (say "sy-AT-ih-kuh"). For more information, see the topic Sciatica.

Nerve-related problems, such as tingling, numbness, or weakness in one leg or in the foot, lower leg, or both legs. Tingling may begin in the buttock and extend to the ankle or foot. Weakness or numbness in both legs, or loss of bladder and/or bowel control, are symptoms of cauda equina syndrome, which requires immediate medical attention.

Arthritis of the spine

Starts gradually, gets worse over time, and lasts longer than 3 to 6 months.

Is generally worse in the morning or after prolonged periods of inactivity. Arthritis pain gets better when you move around.

Other conditions

Symptoms of diseases that affect the spine depend on the disease. They may include:

Pain that is worse in the affected part of the spine (for instance, if there is a compression fracture, tumour, or infection).

Pain that starts gradually, is constant, and may be sharp or a dull ache. Bed rest doesn't help and may make it worse (for example, tumours on the spine often cause night pain). The pain lasts longer than 2 to 3 weeks.

Fever.

Sensitivity of the spine to touch and pressure.

Pain that wakes you up from sleep.

What Happens

The course of low back pain depends both on its cause and on how well you treat your back.

Most low back pain goes away within several weeks. But after you have had back pain once, you're more likely to have it again. Many people who recover have back pain again within a year, and most people will have it again sometime during their lives.

Long-lasting (chronic) pain not only makes you tired, irritable, and less productive and less active but also can trigger other problems. If your back pain causes you to use your body in different ways (for example, to limp or to sit differently), pain can develop in other areas of the body. Pain can also cause biochemical changes in your body that tend to keep the pain going.

What Increases Your Risk

A risk factor is something that increases your chances of having back pain. Having more risk factors means you have a higher chance of having back pain.

Physical and family risk factors

Being middle-aged or older

Being male

Having a family history of back pain

Having had a back injury before

Being pregnant. A woman's back is significantly stressed by carrying a baby.

Risk factors you can change with lifestyle changes

Not getting regular exercise

Doing a job or other activity that requires long periods of sitting, heavy lifting, bending or twisting, repetitive motions, or constant vibration, such as using a jackhammer or driving certain types of heavy equipment

Smoking. People who smoke are more likely than people who don't smoke to have low back pain.

Being overweight. Excess body weight, especially around the waist, may put strain on your back, although this has not been proved. But being overweight often also means being in poor physical condition, with weaker muscles and less flexibility. These can lead to low back pain.

Having poor posture. Slumping or slouching on its own may not cause low back pain. But after the back has been strained or injured, bad posture can make pain worse. "Good posture" generally means your ears, shoulders, and hips are in a straight line. If this posture causes pain, you may have another condition such as a problem with a disc or bones in your back.

Being under stress. Stress and other emotional factors are believed to play a major role in low back pain, particularly chronic low back pain. Many people unconsciously tighten their back muscles when they are under stress.

Risk factors you might change with medical treatment

Having long periods of depression

Using medicines long-term that weaken bones, such as corticosteroids

Having an illness or disease that causes chronic coughing

When to Call a Doctor

Call 911 or other emergency services immediately if:

Back pain occurs with chest pain or other symptoms of a heart attack.

A person has signs of damage to the spine after an injury (such as a car crash, fall, or direct blow to the spine). Signs may include:

Being unable to move part of the body.

Severe back or neck pain.

Weakness, tingling, or numbness in the arms or legs.

Call your doctor now if:

You have new numbness in your legs or numbness in your legs that is getting worse.

You have new weakness in your legs or weakness in your legs that is getting worse. (This could make it hard to stand up.)

You have a new loss of bowel or bladder control.

You have new or increased back pain with fever, painful urination, or other signs of a urinary tract infection.

You have long-term back pain that suddenly gets much worse, and you did not cause it by being more active.

You have a history of cancer or HIV infection, and you have new or increased back pain.

Examinations and Tests

Your doctor will begin by asking questions about your medical history, your symptoms, and your work and physical activities. He or she will also do a physical examination. The questions and examination can help your doctor rule out a serious cause for your pain. Your doctor may also ask questions about stress at home and at work that may make you more susceptible to chronic pain.

If your back pain has lasted for less than 6 weeks, it may be best to wait to do any testing. This is because most back pain goes away on its own in a month or so.

But if you have a back pain problem that has lasted longer than 6 weeks, or if your doctor thinks you may have more than muscle pain, it might be time for a test.

"I thought, 'Okay, it will hurt for a day or two, and that's it.' But it lasted a lot longer. It took about 3 weeks. I guess we're used to fast cures. We take an aspirin, and the headache goes away. We take the antibiotic, and the infection disappears." — Lorna

If over-the-counter medicines combined with these treatments have not helped, your doctor may recommend another medicine. In some cases an antidepressant such as duloxetine can help. If pain is very bad, your doctor may have you try a week or two of an opioid pain reliever such as tramadol. Be sure to discuss the risks and the possible benefits of all medicines with your doctor.

Prevention

There is no clear evidence that you can prevent low back pain. But there are some things you can do that may help prevent it. And they can prepare you for faster recovery if you do have low back pain.

Living With Low Back Pain

Almost everyone has low back pain at some time. The good news is that most low back pain will go away in a few days or weeks with some basic self-care. This includes first aid, self-massage and using heat or ice.

Ease back into your daily activities

Some people are afraid that doing too much may make their pain worse. In the past, people stayed in bed, thinking this would help their backs. Now experts think that, in most cases, getting back to your normal activities is good for your back, as long as you avoid things that make your pain worse.

For the first day or two of pain, take it easy. But as soon as possible, get back to your normal daily life and activities.

Movement helps your muscles stay strong. Lying down for too long can make your problem worse.

If you are an athlete, return to your activity carefully. Choose a low-impact option until your pain is under control.

Think about your posture, whether you are sitting or standing. Slumping or slouching alone may not cause low back pain. But after the back has been strained or injured, bad posture can make pain worse. "Good posture" generally means your ears, shoulders, and hips are in a straight line. If this posture causes pain, you may have another condition such as a problem with a disc or bones in your back.

Stretch and strengthen your back

When you no longer have acute pain, you may be ready for gentle strengthening exercises for your stomach, back, and legs, and perhaps for some stretching exercises. Exercise may not only help decrease low back pain but also may help you recover faster, prevent reinjury to your back, and reduce the risk of disability from back pain.

Walking is the simplest and perhaps the best exercise for the low back. Your doctor or a physiotherapist can recommend more specific exercises to help your back muscles get stronger. These may include a series of simple exercises called core stabilization. The muscles of your trunk, or core, support your spine. Strengthening these muscles can improve your posture, keep your body in better balance, and decrease your chance of injury.

Take care of stress

Stress and low back pain can create a vicious circle. You have back pain, and you begin to worry about it. This causes stress, and your back muscles begin to tense. Tense muscles make your back pain worse, and you worry more ... which makes your back worse ... and so on.

Manage your weight

Extra body weight, especially around the waist, may put strain on your back.

If you want to get to a healthy weight and stay there, lifestyle changes will work better than dieting.

Here are the three steps to reaching a healthy weight:

Eat ahealthy diet.

You may be tempted to do a diet overhaul and change everything about the way you eat. But you will be more successful at staying with the changes you make if you pick just one eating habit at a time to work on.

Get moving. Try to make physical activity a regular part of your day, just like brushing your teeth. Start small, and build up over time. Moderate activity is safe for most people, but it's always a good idea to talk to your doctor before you start an exercise program.

Change your thinking. Our thoughts have a lot to do with how we feel and what we do. If you can stop your brain from telling you discouraging things and have it start encouraging you instead, you may be surprised at how much healthier you'll be—in mind and body.

Quit smoking

People who smoke take longer to heal—from any injury, not just back pain. If you stop smoking, you may feel better sooner.

People who smoke are also much more likely to have back pain than people who don't smoke. This is because the nicotine and other toxins from smoking can keep spinal discs from getting all the nutrients they need from the blood, making disc injury more likely. These discs cushion the bones in your spine. An injured disc can cause low back pain.

Medications

Medicine can decrease low back pain and reduce muscle spasms in some people. But medicine alone isn't an effective treatment for low back pain. It should be used along with other treatments, such as walking, and using heat or ice.

Medicine choices

There are several medicines your doctor may recommend, depending on how long you have had pain, what other symptoms you have, and your medical history. Be safe with medicines. Read and follow all instructions on the label.

The medicines recommended most often are:

Acetaminophen (Tylenol) and non-steroidal anti-inflammatory drugs like ibuprofen and naproxen. You can buy these medicines without a prescription. Some of them also come in stronger doses. For those, you'll need a prescription.

Muscle relaxants. These medicines can help with severe muscle spasms that happen when the back pain starts (acute phase). Side effects, such as drowsiness, are common.

Opioid pain relievers. These are very strong medicines that are sometimes tried to ease severe back pain that has not been controlled by other medicines. They are usually taken for only 1 to 2 weeks.

Antidepressants. Some of these medicines, such as amitriptyline and duloxetine, not only treat depression but also may help with chronic pain.

Other medicines sometimes used for low back pain are:

Anesthetic or steroid injections. These have been prescribed for chronic low back pain, but they have not been researched enough to know if they work well for back pain. They may give short-term relief from leg pain related to a back problem.

Botox injection. This is a shot into the back muscles. It has not been well tested for chronic low back pain.

Medicines that work for some people don't work for others. Let your doctor know if the medicine you are taking doesn't work for you. You may be able to take another medicine for your back pain.

Surgery

When you're in a lot of pain, you might wonder if you need surgery to fix what's wrong so that you can feel better.

Every case is different. But most people don't need surgery for low back pain.

When surgery may help

Most back surgeries are done to treat nerve pain from herniated discs. Surgery might be an option when a disc problem causes pain in your leg that prevents you from doing everyday tasks. You may have pain, numbness, or tingling through your buttock and down the back of your leg (sciatica) or in the front of your thigh.

Rehabilitation after surgery

A comprehensive rehabilitation program is very important after most back surgery. As you regain flexibility, recondition your back and stomach muscles, and increase your endurance for activity, you increase your chances of treatment success.

If you are unable or unwilling to do physiotherapy after surgery, you may not be a good candidate for surgery.

Deciding whether to have surgery

If you and your doctor are considering surgery, get as much information as you can about possible results, and consider whether you will be willing to do physiotherapy after surgery. It is also a good idea to get a second opinion before you decide to have surgery.

Back surgery isn't always successful. Depending on the condition, you may still have back pain after surgery.

Other Treatment

You can choose from a number of treatments for your low back pain. Because some of these treatments are new or not yet well researched, they may not be covered by your provincial health plan, private health insurance, or your Workers' Compensation Board.

The following complementary treatments are often used for low back pain.

Massage may reduce low back pain for a short time. It is probably most effective if you also learn to do exercises for your back and learn the best ways to lift and move to protect your back.

Biofeedback hasn't been well studied as a treatment for low back pain. Recent research hasn't shown that biofeedback is effective for controlling low back pain.

Acupuncture may help reduce pain and increase the ability to be active for a short time after treatment but not any more than other treatments.footnote 1

Acupressure uses pressure on certain points in the body to decrease symptoms. Small studies suggest that acupressure reduces pain and allows a person to be more active.footnote 2

Relaxation techniques can help reduce muscle tension, stress, and depression.

Yoga is another way to stay active and get help with relaxation and managing stress. Small studies suggest that yoga classes may help people with chronic low back pain control their symptoms and stay more active.footnote 3, footnote 4 It is not clear whether yoga is more helpful than other activity or treatment for chronic low back pain. There are different types of yoga. Talk to your doctor or physiotherapist before you start a yoga program.

Capsaicin cream may help relieve pain.footnote 5 Capsaicin is a substance contained in cayenne peppers. Capsaicin cream is applied directly to the skin over the painful area.

Here are some other treatment choices to think about:

Self-care techniques:

Back school teaches you all about back care, how to stand and sit, and how to move your body in a safer way.

Radiofrequency ablation of nerves. This may reduce chronic low back pain in some people by preventing pain signals from reaching the brain. It is sometimes used for pain from problems with the small joints in the spine called facet joints.

An intrathecal pain pump. This is a small tube inserted under the skin and deeper tissues along the midline of the back and into the spinal canal. The tube connects to a small reservoir of medicine inserted under the skin of your belly. The medicine is regularly delivered to the area of pain through the tube.

Coping With Chronic Back Pain

Low back pain can take a toll on your mental health. You may feel fear, frustration, and anger or have depression and anxiety because of ongoing pain. Those common reactions can make your pain last even longer. If pain is starting to get you down:

Let people know when you need a helping hand. Ask family members or friends to help out with physical tasks you can't do right now.

Be honest with your doctor about your pain. Ask for a referral to a counsellor or pain management specialist. A prescription antidepressant or antianxiety medicine may also help with chronic pain.

Work with your health professionals and your work supervisor to make a return-to-work plan, if needed. Ask for an ergonomic consultation if you need to learn how to do some of your job duties differently to avoid hurting your back again.

One Man's Story:

"I started feeling sad and angry a lot. I didn't want to do anything. My back was hurting more. I was having trouble focusing on my work. My life just started feeling smaller and smaller."— Ravi

Emotional support is important

You may have to lean on friends and family when facing difficult situations caused by chronic pain or other problems. Your loved ones can play an important role in supporting your recovery. Your doctor and community also may give you extra support.

Asking for support from others is not always easy. It can be hard to tell someone about your problems. But don't be afraid to ask for help.

Where you can get support

Family. Family members can help you cope by giving you comfort and encouragement.

Friends. Building strong relationships with others is important for your emotional well-being. Helping is a big part of friendship. At times you may be the one who encourages a friend.

Counselling. Professional counselling can help you cope with situations that interfere with your life and cause stress. Counselling can help you understand and deal with your pain. You can learn ways to stop negative thoughts. See the topic Stop Negative Thoughts: Choosing a Healthier Way of Thinking.

Your doctor. Find someone you trust and feel comfortable with. Be open and honest about your fears and concerns. Your doctor can help you get the right treatments, including treatment for depression or other problems.

Religious groups. Religious or spiritual groups may help you meet people and get involved in the community. Some religious organizations can help you get counselling or other social support services.

Social groups. Social groups can help you meet new people and get involved in activities you enjoy.

Community support groups. In a support group, you can talk to others who have dealt with the same problems or illness as you. You can encourage one another and learn ways of coping with tough emotions.

One Woman's Story:

"I really work at finding the good things in my day. It helps me get through the day, and I think it makes my pain not bother me as much."— Patty

Other Works Consulted

Agency for Healthcare Research and Quality (2010). Complementary and Alternative Therapies for Back Pain II (Evidence Report/Technology Assessment No. 194). Rockville, MD: Agency for Healthcare Research and Quality. Also available online: http://www.ahrq.gov/downloads/pub/evidence/pdf/backpaincam/backcam2.pdf.

American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57(8): 1331–1346.

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